United States Army Institute for Surgical Research, Fort Sam Houston San Antonio, San Antonio, Tex 78234, USA.
J Vasc Surg. 2012 Sep;56(3):728-36. doi: 10.1016/j.jvs.2012.02.048. Epub 2012 Jul 13.
The purpose of this study was to examine the anatomic distribution and associated mortality of combat-related vascular injuries comparing them to a contemporary civilian standard.
The Joint Trauma Theater Registry (JTTR) was queried to identify patients with major compressible arterial injury (CAI) and noncompressible arterial injury (NCAI) sites, and their outcomes, among casualties in Iraq and Afghanistan from 2003 to 2006. The National Trauma Data Bank (NTDB) was then queried over the same time frame to identify civilian trauma patients with similar arterial injuries. Propensity score-based matching was used to create matched patient cohorts from both populations for analysis.
Registry queries identified 380 patients from the JTTR and 7020 patients from the NTDB who met inclusion criteria. Propensity score matching for age, elevated Injury Severity Score (ISS; >15), and hypotension on arrival (systolic blood pressure [SBP] <90) resulted in 167 matched patients from each registry. The predominating mechanism of injury among matched JTTR patients was explosive events (73.1%), whereas penetrating injury was more common in the NTDB group (61.7%). In the matched cohorts, the incidence of NCAI did not differ (22.2% JTTR vs 26.6% NTDB; P = .372), but the NTDB patients had a higher incidence of CAI (73.7% vs 59.3%; P = .005). The JTTR cohort was also found to have a higher incidence of associated venous injury (57.5% vs 23.4%; P < .001). Overall, the matched JTTR cohort had a lower mortality than NTDB counterparts (4.2% vs 12.6%; P = .006), a finding that was also noted among patients with NCAI (10.8% vs 36.4%; P = .008). There was no difference in mortality between matched JTTR and NTDB patients with CAI overall (2.0% vs 4.1%; P = .465), or among those presenting with Glasgow Coma Scale (GCS) <8 (28.6% vs 40.0%; P = 1.00) or shock (SBP <90; 10.5% vs 7.7%; P = 1.00). The JTTR mortality rate among patients with CAI was, however, lower among patients with ISS >15 compared with civilian matched counterparts (10.7% vs 42.4%; P = .006).
Mortality of injured service personnel who reach a medical treatment facility after major arterial injury compares favorably to a matched civilian standard. Acceptable mortality rates within the military cohort are related to key aspects of an organized Joint Trauma System, including prehospital tactical combat casualty care, rapid medical evacuation to forward surgical capability, and implementation of clinical practice guidelines. Aspects of this comprehensive combat casualty care strategy may translate and be of value to management of arterial injury in the civilian sector.
本研究旨在比较战伤相关血管损伤的解剖分布和相关死亡率，并与当代平民标准进行比较。
通过联合创伤救治登记处（JTTR）查询，确定 2003 年至 2006 年期间在伊拉克和阿富汗的伤员中存在主要可压缩性动脉损伤（CAI）和不可压缩性动脉损伤（NCAI）部位及其结局的患者。然后，在同一时间段内查询国家创伤数据库（NTDB），以确定具有类似动脉损伤的平民创伤患者。使用基于倾向评分的匹配方法，从两个群体中创建匹配的患者队列进行分析。
登记处查询从 JTTR 中确定了 380 名符合纳入标准的患者，从 NTDB 中确定了 7020 名患者。对年龄、升高的损伤严重程度评分（ISS；>15）和到达时的低血压（收缩压[SBP] <90）进行倾向评分匹配，结果从每个登记处各获得 167 名匹配患者。在匹配的 JTTR 患者中，主要损伤机制是爆炸事件（73.1%），而 NTDB 组中更常见的是穿透性损伤（61.7%）。在匹配的队列中，NCAI 的发生率没有差异（JTTR 22.2% vs NTDB 26.6%；P=.372），但 NTDB 患者的 CAI 发生率更高（73.7% vs 59.3%；P=.005）。JTTR 队列也发现静脉损伤的发生率更高（57.5% vs 23.4%；P <.001）。总体而言，与 NTDB 对照组相比，匹配的 JTTR 队列的死亡率较低（4.2% vs 12.6%；P=.006），在 NCAI 患者中也观察到这种情况（10.8% vs 36.4%；P=.008）。在总体 CAI 患者中，匹配的 JTTR 和 NTDB 患者之间的死亡率没有差异（2.0% vs 4.1%；P=.465），或在 GCS <8 的患者中（28.6% vs 40.0%；P=1.00）或休克患者中（SBP <90；10.5% vs 7.7%；P=1.00）。然而，在 ISS >15 的 CAI 患者中，JTTR 的死亡率低于平民匹配对照组（10.7% vs 42.4%；P=.006）。
在主要动脉损伤后到达医疗救治机构的受伤军人的死亡率与匹配的平民标准相比具有良好的可比性。在军事队列中可接受的死亡率与有组织的联合创伤系统的关键方面有关，包括战现场战术救治、快速医疗后送至前线手术能力以及实施临床实践指南。这种综合战伤救治策略的各个方面可能会转化并对平民部门的动脉损伤管理具有价值。
